3What is Vitamin D? Actually, a hormone Receptors in many organ systems –Bone, skeletal muscle, brain, prostate, breast, colon, pancreas, immune cellsVitamin D2 = calciferol – about 30% activity of D3Vitamin D3 = cholecalciferol
4Vitamin D synthesis Vit D from skin or diet > Metab in liver to 25-OH-Vit D >Metab in kidneys to 1,25-diOH-Vitamin D3Regulated by parathyroid hormone and serum calcium and phosphorusExcess 25-OH-Vit D and 1,25-diOH-Vit D are catabolized into inactive calcitroic acid and excreted in bile
5What Vitamin D does-- Increases calcium and phosphorus absorption Enhances bone mineral densityIncreases insulin production in pancreasDecreases renin production in kidneysImmunomodulatoryAnti-inflammatoryRole in preventing genetic expression of some cancers (local effect)
7(measured as serum 25-OH-Vit D levels) Vitamin D levels(measured as serum 25-OH-Vit D levels)Deficiency < 20ng/mlInsufficiency = 21-29ng/mlSufficiency >30ng/mlPreferred range = 30-60ng/mlIntoxication >150ng/ml
8Sources of Vitamin D Sunshine – ultraviolet B radiation (290-315nm) 0.5 “minimal erythemal dose”* givesabout 3000IU of vitamin D3*0.5 minimal erythemal dose =about 5-10** minutes of exposureof arms and legs to direct sunshine,**Depending on time of day, season, cloudcover, extent of air pollution, latitude, bodymass, amount of exposed skin, UVB protection,and skin sensitivity (complexion & genetics)
9It’s GOOD in moderation! A word about sunshine . . .It’s GOOD in moderation!10-15 minutes dailyShort sleeves and pantsWithout hat or sunscreenSPF 15 or higher blocks 99% of UVBWhat about risk of skin cancer?Apply sunscreen after those first minutes!
10“It is virtually impossible to get enough sunshine from November to February above 35 degrees latitude* to stay “sufficient”.*35 degrees latitude is the north border of Georgia, Alabama, and Mississippi, and cuts Arkansas in half just north of Little Rock
11Sources of Vitamin D Dietary (Adults) Salmon 100-1000 IU Sardines IUMackerel IUTuna IUCod liver oil IUShitake mushrooms IUEgg yolk IU
12Sources of Vitamin D Dietary (“Fortified”) Milk, OJ, yogurt, IU/8ozInfant formula IU/8ozButter IU/3.5ozMargarine IU/3.5ozCheeses IU/3ozBreakfast cereals IU/serving
13Sources of Vitamin D Dietary Supplements Prescription Over the Counter Vitamin D2 (ergocalciferol) 50,000IU/capDrisdol liquid vit D2 8,000IU/mlOver the CounterMultivitamin / Prenatal 400IUVitamin D , 800, 1000, or 2000 IUInfant drops IU/dose
14Sources of Vitamin D Dietary (Infants) Human Breast Milk Vitamin D content varies based on Mom’s Vitamin D status,which varies based on hersunlight exposure and dietary intake.Range: IU / liter, if mom unsupplementedUp to >800 IU / liter if mom on high-dose Vit D
15DATE: August 29, 2008It is clear that vitamin D content of human milk is variable and directly related to maternal vitamin D status. Human milk is not deficient in vitamin D per se; rather, it is deficient in vitamin D when mother is deficient. Vitamin D transfer into mothers’ milk is predictable: a deficient woman has little to transfer to her infant via her milk; if her status improves, transfer of vitamin D in her milk to the baby will also. Maternal vitamin D deficiency and resultant nutritional rickets in her nursing infant is preventable: supplementation of the infant with vitamin D will ameliorate deficiency in that age group, but does not address maternal needs. Adverse effects associated with vitamin D deficiency affect bone development and innate immunity such that no woman and her baby should be deficient. We must prescribe a safe intervention that will achieve sufficiency in both mother and infant and not blame human milk as the culprit, but rather, see the problem as the larger public health issue that it is.Caroline Chantry, MD Karla Shepard RubingerPresident Executive DirectorAcademy of Breastfeeding Medicine Academy of Breastfeeding Medicine140 Huguenot Street, 3rd floorNew Rochelle, NY
16Human Breast Milk is not deficient in Vitamin D; Modern life is deficient in sunshine!
17Risk Factors for Vit D Deficiency Reduced skin synthSunscreenPigmentAgingSeason/latitude/timeSkin graftsDec. bioavailabilityMalabsorptionCystic fibrosisCeliac diseaseCrohn’s diseaseGastric Bypass surgeryCholesterol lowering medsObesity
18Risk Factors for Vit D Deficiency Increased catabolismAnticonvulsantsGlucocorticoidsOthersIncreased urinary loss of 25-OH-DNephrotic syndromeDecreased synthesis of 25-OH-DLiver failureDecreased synthesis of 1,25-diOH-DChronic kidney disease
19Risk Factors for Vit D Deficiency Heritable Disorders – (Rickets)Vit D dependent rickets – type 1Vit D resistant ricketsVit D dependent rickets – type 3AD hypophosatemic ricketsX-linked hypophosphatemic ricketsAcquired disordersTumor-induced osteomalaciaPrimary hyperparathyroidismGranulomatous disorders (sarcoid, TB)Hyperthyroidism
20Risk Factors for Vit D deficiency in infants Mom who is “insufficient” or “deficient” during pregnancy or lactationBaby is both exclusively breastfedAND sheltered / protected from sunlight.Babies born in fall/winterBabies in full-time daycareLiving above 35 degrees N latitudeBabies born prematurely
21Recommendations – Breastfeeding Babies Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!AAP: 400 IU vitamin D3 / daySensible sun exposureIU vitamin D3 / day is safe, if necessary to treat deficiency
22Supplementation of the nursing infant with oral vitamin D Supplementation of the nursing infant with oral vitamin D does not address the issue of why the antirachitic activity of the mother’s milk is low --- namely, that her vitamin D status is poor.Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):
23Correlation of Maternal and Infant 25-OH-Vit D levels Maternal Infant Maternal InfantVit D Vit D serum serumSuppl Suppl (OH)D (OH)D2000IU/day4000IU/day6400IU/day400IU/day IU/dayFrom: Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.Wagner C, Hulsey TC, Fanning D, et al High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month follow-up pilot study. Breastfeeding Medicine 1(2):59-70.
24“We understand more fully now that this deficiency is not caused by something that is inherently wrong or missing in mother’s milk but rather by inadequate maternal dietary vitamin D intake and the resultant low concentrations in the mother’s milk.”Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):
25Supplementation of Breastfeeding Mothers “Lactating women given 4000 IU of vitamin D3 per day not only had an increase in the level of 25-OH vitamin D to more than 30 ng/ml, but were able to transfer enough vitamin D3 into their milk to satisfy an infant’s requirement.”Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant.Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.
26“Recommendations” – Lactating Mothers Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!1000 – 4000 IU vitamin D3 / day50,000 IU vitamin D2 q 2 weeks to treat deficiencyUp to 4000 IU vitamin D3/day is safe for 5 mosUp to 6400 IU / day has been used for 3 months without problems.
27SummaryVitamin D deficiency is much more widespread than previously thoughtVitamin D deficiency is a factor in many diseases, not only rickets and osteoporosis.Modern life is deficient in sunshine, and thus in vitamin D.Some form of vitamin D supplementation may be appropriate for many breastfeeding mothers / babies.
28Summary“In the future, we expect that by treating the mother with a sufficient dose of vitamin D, both mother and her recipient infant will achieve normal vitamin D status.”Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):
29Mississippi Breastfeeding Medicine Clinic, PLLC Rebecca B. Saenz,MD, IBCLC, FABM111-A Depot DriveMadison, MSFaxAnd on Facebook!